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Enhanced recovery after spine surgery: A systematic review

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DOI: 10.3171/2019.1.FOCUS18700

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NEUROSURGICAL
  FOCUS Neurosurg Focus 46 (4):E3, 2019

Enhanced recovery after spine surgery: a systematic

review
Mazin Elsarrag, MS, Sauson Soldozy, BA, Parantap Patel, BS, Pedro Norat, MD,
Jennifer D. Sokolowski, MD, PhD, Min S. Park, MD, Petr Tvrdik, PhD, and
M. Yashar S. Kalani, MD, PhD
Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia

OBJECTIVE  Enhanced recovery after surgery (ERAS) is a multidimensional approach to improving the care of surgical
patients using subspecialty- and procedure-specific evidence-based protocols. The literature provides evidence of the
benefits of ERAS implementation, which include expedited functional recovery, decreased postoperative morbidity, re-
duced costs, and improved subjective patient experience. Although extensively examined in other surgical areas, ERAS
principles have been applied to spine surgery only in recent years. The authors examine studies investigating the appli-
cation of ERAS programs to patients undergoing spine surgery.
METHODS  The authors conducted a systematic review of the PubMed and MEDLINE databases up to November 20,
2018.
RESULTS  Twenty full-text articles were included in the qualitative analysis. The majority of studies were retrospective
reviews of nonrandomized data sets or qualitative investigations lacking formal control groups; there was 1 protocol for a
future randomized controlled trial. Most studies demonstrated reduced lengths of stay and no increase in rates of read-
missions or complications after introduction of an ERAS pathway.
CONCLUSIONS  These introductory studies demonstrate the potential of ERAS protocols, when applied to spine proce-
dures, to reduce lengths of stay, accelerate return of function, minimize postoperative pain, and save costs.
https://thejns.org/doi/abs/10.3171/2019.1.FOCUS18700
KEYWORDS  enhanced recovery after surgery; fast-track recovery; spine surgery; scoliosis; minimally invasive
surgery; degenerative spine disease

E
nhanced recovery after surgery (ERAS) is a mul-
tidisciplinary, multimodal approach to improving
surgical outcomes by using subspecialty- and proce-
dure-specific evidence-based protocols in the care of surgi-
cal patients.33 Peer-reviewed ERAS protocols are available
for various surgical disciplines and procedures. Despite
technical differences in these protocols, a common motif
is present: minimization and improvement of the stress re-
sponse. The proposed rationale suggests that by maintain-
ing homeostasis, untoward effects such as postoperative
catabolism, pain, and immune dysfunction can be attenu-
ated.25,32,47 Components and workflow of a typical ERAS
pathway are demonstrated in Fig. 1.
Although Fearon et al.13 became the first to formalize
such protocols, similar systematic approaches to periop-
erative care were espoused as early as the 1990s. Initially
described as “fast-track surgery” designed to expedite re-
covery and decrease length of stay (LOS), ERAS has since
evolved in both language and approach to focus on opti-
mizing the perioperative experience of surgical patients.25
To date, ERAS has been implemented in various surgical
specialties.4,5,7,22,30,38,41,45,49,57 As the earliest discipline to
implement ERAS, colorectal surgery offers a substantial
body of literature supporting its benefits.10 For example, a
meta-analysis of 16 randomized controlled trials (RCTs)
of patients undergoing colorectal surgery found a signifi-
cant reduction of overall morbidity and LOS with use of an
ERAS protocol.21

ABBREVIATIONS  ACDF = anterior cervical discectomy and fusion; AD = accelerated discharge; AIS = adolescent idiopathic scoliosis; ERAS = enhanced recovery after
surgery; ERSS = enhanced recovery after spine surgery; LOS = length of stay; PCA = patient-controlled analgesia; PSF = posterior spinal fusion; RCT = randomized con-
trolled trial; TD = traditional discharge; TLIF = transforaminal lumbar interbody fusion.
SUBMITTED  December 1, 2018.  ACCEPTED  January 25, 2019.
INCLUDE WHEN CITING  DOI: 10.3171/2019.1.FOCUS18700.

©AANS 2019, except where prohibited by US copyright law Neurosurg Focus  Volume 46 • April 2019 1
Elsarrag et al.
FIG. 1. Components and workflow of a typical ERAS pathway. Copyright American Association of Nurse Anesthetists. Published
with permission.
From a healthcare management perspective, ERAS
demonstrates financial benefits as well.29 A meta-analysis
of 10 RCTs consisting of patients undergoing noncolorec-
tal abdominal surgery calculated a mean cost reduction of
$5109.10 (p < 0.001) in the ERAS versus control groups,
which was attributed to the combined effect of decreased
LOS and no increase in postoperative readmission in
ERAS groups.51 Furthermore, cost savings often surpass
the initial ERAS implementation costs.28,29 Patients’ posi-
tive experiences following an ERAS protocol also indicate
subjective benefit.31 A study of 95 patients undergoing
colorectal surgery observed an increased sense of readi-
ness for discharge (41st to 99th percentile), satisfaction with
pain control (43rd to 98th percentile), and likelihood of the
patient recommending the hospital (32nd to 89th percen-
tile) in the ERAS group compared to the control group.48
Given the apparent benefits of ERAS programs in other
surgical disciplines, it is not surprising that its implemen-
tation in spine surgery is becoming increasingly common.
Wainwright et al.52 provided an excellent overview for re-
covery barriers in the postoperative period with regard to
spine surgery, citing that spinal procedures are associated
with high amounts of pain, slow return of function, and
prolonged hospital stays, among other complications. Al-
2 Neurosurg Focus  Volume 46 • April 2019
though they performed a wide literature review examin-
ing the adoption of ERAS protocols in spine surgery, the
majority of studies identified at the time examined only
individual components of ERAS pathways rather than
comprehensive programs. Nonetheless, the evidence they
reviewed indicated that ERAS principles would likely
expedite return to function and minimize postoperative
morbidity.
The aim of this systematic review was to identify and
examine studies investigating the application of formal
ERAS programs to patients undergoing spine surgery.
Methods
A literature search using PubMed and MEDLINE data-
bases on November 20, 2018, was performed using the key-
words listed below in combination with Boolean “AND”
and “OR” phrases. Titles and abstracts were screened
for relevance, and articles describing implementation of
enhanced-recovery programs in the context of any spine
surgery were included. Bibliographies of works included
in the final qualitative synthesis were hand searched for
additional relevant studies not found in the original search.
Case reports, review articles, or other works without origi-

FIG. 2. Flow diagram showing study selection process.
nal data and studies examining only multimodal analgesia
or comparing the efficacy of various analgesic medica-
tions were excluded. Given that ERAS protocols are de-
signed to address several factors related to perioperative
patient care, we did not include studies examining the ef-
fect of single variables on outcomes in the absence of an
enhanced-recovery framework. A flow diagram detailing
methods for selection of studies is presented in Fig. 2. Sur-
veyed outcomes were LOS and rates of readmissions and
complications. Data from the included studies were inde-
pendently extracted by the first author.
Search terms for spine surgery: “spine,” “spinal,” “lum-
bar,” “cervical,” “decompression,” “discectomy,” “diske-
ctomy,” “laminectomy,” “laminotomy,” “foraminotomy,”
“facetectomy,” “spondylolisthesis,” “scoliosis,” “kypho-
plasty,” “vertebroplasty,” “laminoplasty,” “TLIF,” “PLIF,”
“ALIF,” “LLIF,” “XLIF,” “OLIF,” “Smith-Petersen os-
teotomy,” “Smith Petersen osteotomy,” “Smith-Peterson
osteotomy,” “Smith Peterson osteotomy,” “Ponte osteoto-
my,” “pedicle subtraction osteotomy,” “vertebral column
resection,” “anterior column realignment.” Search terms
for ERAS: “fast track,” “fast-track,” “ERAS,” “enhanced
recovery protocol,” “enhanced recovery pathway,” “en-
hanced recovery program,” “enhanced recovery system,”
“enhanced recovery strategy,” “enhanced recovery after
surgery,” “clinical pathway,” “critical pathway,” “multi-
Elsarrag et al.
modal perioperative,” “perioperative protocol,” “postop-
erative protocol,” “postoperative recovery,” “accelerated
recovery,” “recovery program,” “recovery pathway,” “mul-
timodal postoperative.”
Results
As enhanced-recovery programs are not currently
widely adopted within spine surgery, many investigational
studies report their initial approaches to and results of in-
troducing such programs. We categorized these studies
as surgery in the lumbar spine, surgeries for correction of
scoliosis or deformity, and surgeries of the cervical spine.
Combined cervical/lumbar cohorts were included under
cervical surgery.
Lumbar Spine
Soffin et al.46 designed an enhanced-recovery path-
way for 61 patients undergoing lumbar microdiscectomy
or decompression surgery. Preoperative elements of their
protocol included patient education, limited fasting, and a
carbohydrate beverage 4 hours prior to surgery. Adjunc-
tive nonopioid analgesics and antiemetic prophylaxis were
provided. Intravenous fluids and warming were targeted
to maintain euvolemia and normothermia. A minimally
invasive approach to both surgeries was utilized. Foley
Neurosurg Focus  Volume 46 • April 2019 3
Elsarrag et al.
catheters and drains were avoided. Other components of
postoperative management included cessation of intrave-
nous fluids, prompt oral intake, and rapid mobilization.
They reported a median LOS of 279 minutes overall. No
readmissions within 3 months of surgery were seen.
Wang et al.54 proposed an ERAS protocol for 42 pa-
tients undergoing lumbar fusion. They did not implement
pre- and postoperative elements of the pathway but rather
focused on the operative approach and anesthetic consid-
erations. The procedure consisted of a minimally invasive
transforaminal lumbar interbody fusion (TLIF) via an en-
doscopic channel with percutaneous pedicle screw fixation
and was performed entirely under conscious sedation and
with application of local anesthetic agents. In their series,
laryngeal access was not obtained. Foley catheters were
not placed, and narcotic medications were not utilized.
They reported no intraoperative events related to anesthe-
sia, sedation, or medical events. All patients were ambula-
tory on either the day of or the day after surgery. A follow-
up study by Wang et al.53 retrospectively compared the first
38 patients treated with their ERAS protocol to a group
of 15 patients who underwent minimally invasive TLIF
prior to the introduction of the enhanced-recovery se-
quence. Differences between the two groups included the
use of general anesthesia and surgery without utilization
of the endoscope or the addition of liposomal bupivacaine
in the comparison group. Shorter LOS (1.23 vs 3.9 days,
p = 0.009), reduced operative time, less blood loss, fewer
complications, and a 15.2% lower total cost for acute-care
hospitalization were observed in the ERAS group.
Although not utilized by them in this series, Wang et
al.54 provided recommendations regarding other peri-
operative components of a complete enhanced-recovery
pathway, including patient education; nutrition; carbohy-
drate loading; avoiding routine use of drains and urinary
catheterization; targeting euvolemia, normothermia, and
normotension; and early postoperative mobilization and
enteral nutrition.
Grasu et al.20 retrospectively evaluated the efficacy of
an enhanced recovery after spine surgery (ERSS) program
in 56 patients who underwent spine surgery for metastatic
tumors. A variety of open and minimally invasive proce-
dures were utilized. Their pathway included preoperative
education and multimodal management of pain and anxi-
ety, carbohydrate loading with limited fasting, euvolemia,
normothermia, utilization of minimally invasive tech-
niques when possible, and other elements. Postoperatively,
emphasis was placed on early ambulation, rehabilitation,
and oral intake. Compared to 41 patients in the preprotocol
cohort, those in the ERSS group achieved slightly better
average pain control. However, no significant differences
were seen with regard to 30-day readmission rates, com-
plications, and LOS (6.3 vs 6.8 days, p = 0.590). The au-
thors noted that patients with advanced metastatic disease
or terminal illness may have prolonged hospitalizations
for cancer care unrelated to surgical procedures for which
they were admitted.
Nazarenko et al.36 applied a fast-track program to 23
patients who underwent microdiscectomy for lumbosa-
cral disc herniation and compared results to 25 patients
undergoing the same procedure managed with a standard
4 Neurosurg Focus  Volume 46 • April 2019
perioperative algorithm. Central aspects of their fast-track
approach were presurgical optimization, patient education
emphasizing the patient’s role in rehabilitation, early phys-
iotherapy, and goal-directed discharge. Patients in the fast-
track group had a faster recovery and significantly shorter
LOS (2.3 vs 3.8 days, p < 0.05). Furthermore, patient satis-
faction questionnaires revealed improved pain control and
improved overall patient experience in the fast-track group.
Scanlon and Richards43 instituted early ambulation
and enteral nutrition and optimized anesthetic agents to
achieve faster return to baseline in 27 patients undergo-
ing lumbar decompression. Using such a program, they
reported same-day discharge without increased 30-day re-
admissions. Although not including a formal control group
in the study design, the investigators reported that patients
undergoing this surgery at their institution had historically
been admitted for 1–3 days postoperatively.
Fleege et al.14 described a fast-track protocol for patients
undergoing one- to two-segment stabilization for degen-
erative lumbar spine pathologies. By ensuring patient edu-
cation, mobilization on the day of surgery, and aggressive
rehabilitation, the investigators were able to reduce hospi-
tal LOS from 10.9 to 6.2 days.
Zhang et al.56 explored the feasibility of enhanced re-
covery after surgery in patients with lumbar spondylolis-
thesis undergoing mobile microendoscopic discectomy
and TLIF. They found that the ERAS pathway reduced
intraoperative bleeding, shortened LOS, improved postop-
erative pain, and promoted rapid rehabilitation of patients
without impacting long-term outcomes.
Bradywood et al.6 implemented a care pathway for pa-
tients undergoing lumbar fusion. They hypothesized that
variation in postoperative management was a significant
cause of inefficiency in their healthcare system and cre-
ated a protocol to address pain control, time points at
which to discontinue patient-controlled analgesia (PCA)
and Foley catheters, frequency of mobility, and communi-
cation between healthcare teams, among other factors. In
their analysis of 458 patients, they found that the clinical
care pathway decreased mean LOS from 3.9 to 3.4 days
(p < 0.001), resulted in a more favorable disposition (75%
vs 64% discharged to home, p = 0.002), and significantly
reduced duration of urinary catheterization compared to
historical controls. No changes were seen in 30-day read-
missions or patient satisfaction data.
Correction of Scoliosis and Spinal Deformity
A clinical pathway by Muhly et al.35 incorporated mul-
timodal analgesia, early mobilization, prompt discontinu-
ation of opioid medications, and other measures for rapid
recovery in adolescents undergoing posterior spinal fusion
(PSF) for idiopathic scoliosis. Study groups included his-
torical controls (n = 134), patients from a transition period
when the program was introduced and modified (n = 104),
and patients in the rapid-recovery pathway (n = 84). A de-
crease in the mean LOS from 5.7 to 4 days and reduced
pain scores on postoperative days 0 and 1 were observed
after transition into and full implantation of the rapid-re-
covery pathway. Similar rates of 30-day readmissions were
observed.
Gornitzky et al.19 compared 58 patients undergoing a

rapid-recovery pathway after PSF for adolescent idiopathic
scoliosis (AIS) to 81 historical controls. Similar to Muhly
et al.,35 they instituted early rehabilitation, transition to oral
intake, and prompt discontinuation of drains, catheters, and
opioid analgesics. The results showed significantly faster
time to urinary catheter removal (1.5 vs 2.0 days) and PCA
discontinuation (2.0 vs 3.6 days) and a shorter LOS (3.5 vs
5.0 days) (p < 0.001 for all comparisons). Mean daily pain
scores were significantly reduced on postoperative days 0,
1, and 2. There was no difference in 30-day readmission
rates between the groups.
Chan et al.8 examined the feasibility and outcome of an
accelerated recovery protocol in 74 adolescents undergoing
PSF for correction of idiopathic scoliosis. Fixed discharge
criteria were set, and postoperative recovery milestones
were established to address the removal of urinary cath-
eters and subfascial drains, as well as timing of dressing
changes, mobilization, and PCA discontinuation. Methods
to improve postoperative pain management, shorten op-
erative time, and minimize blood loss were implemented.
Intraoperative antiemetic prophylaxis was provided. Com-
pared to 33 historical controls, the enhanced-recovery
group had a shorter mean LOS (5.2 vs 3.6 days). Only 1
patient failed to meet milestones, and the only complica-
tion was a superficial wound infection in 1 patient that was
managed on an outpatient basis. No other complications
or readmissions were seen within the 4-month follow-up
period.
Fletcher et al.15 evaluated the efficacy of an accelerated
discharge (AD) pathway for patients undergoing PSF for
AIS. They compared the AD protocol at one center to a
traditional discharge (TD) pathway at a different center.
The pathway emphasized early transition to oral pain
medications, frequent mobilization with physical thera-
py, and discharge regardless of a return of bowel function.
One hundred five patients were treated by an AD pathway,
whereas 45 patients were managed using a TD pathway.
The AD group had a 48% shorter LOS (2.2 vs 4.2 days, p <
0.0001) and significantly fewer total complications than the
TD cohort. There was no difference in readmission rates
between groups. In their earlier work studying patients
with AIS undergoing PSF, Fletcher et al.16 compared 279
patients managed with an AD pathway at one institution to
86 patients treated with a standard discharge pathway at a
separate institution. Their results demonstrated that an AD
pathway prioritizing early transition to oral pain medica-
tions and a solid diet, frequent mobilization with physical
therapy, and early removal of drains and urinary catheters
resulted in earlier discharge (2.9 vs 4.3 days, p < 0.0001)
and no significant increase in complications.
Sanders et al.42 tested an AD pathway for the man-
agement of AIS in 90 patients compared to 194 patients
managed with a TD pathway. Their pathway incorporat-
ed similar measures to those described by Fletcher et al.
Shorter mean durations of hospitalization were seen when
comparing the two groups (3.7 vs 5.0 days, p < 0.001). Inci-
dence of complications or readmissions was not increased
in the AD group. Hospital charges for postoperative care
were 22% lower ($18,360 vs $23,640, p < 0.0001) in the
AD cohort compared to the TD group.
Rao et al.40 conducted a retrospective review of adoles-
Elsarrag et al.
cents who had undergone PSF before and after implemen-
tation of pathways to standardize aspects of postoperative
care such as pain, management of incisions, nutrition, void-
ing, and activity. A later revision to the protocol required
removal of the Foley and epidural catheters a day earlier.
Data were gathered for 51 patients managed before intro-
duction of any protocols, 100 patients who were managed
with the first protocol, and 39 patients managed with the
second protocol. Clearance for discharge by physical ther-
apy, time to removal of Foley catheter and epidural/PCA,
and LOS were significantly decreased in patients managed
with the final protocol.
Cervical and Combined Cervical/Lumbar Cohorts
Sivaganesan et al.44 performed a retrospective analy-
sis comparing patients who underwent elective lumbar or
cervical spine surgery before and after implementation of
an ERAS protocol (n = 1579 and 151 for preprotocol and
postprotocol, respectively). Procedures included anterior
cervical discectomy and fusion (ACDF), microdiscecto-
my, and laminectomy with or without fusion. Elements
of the protocol included appropriate thromboembolism
prophylaxis, use of bracing when indicated, bed rest in
case of durotomy, multimodal pre- and postoperative pain
control, and suitable antibiotic prophylaxis. Early patient
mobilization, drain removal, and discharge planning were
emphasized. Results demonstrated reduced LOS and 90-
day complication rates for postprotocol patients. Discharge
status, readmission rates, and 3-month patient-reported
outcomes were comparable between the two groups. Sub-
group analysis demonstrated no significant difference be-
tween any outcome measures in patients undergoing cervi-
cal surgery, while patients undergoing lumbar surgery in
the ERAS pathway had a significantly shorter LOS (2.9
vs 2.5 days, p = 0.021) and fewer complications (12.8% vs
3.8%, p = 0.002).
Dai et al.11 instituted an ERAS protocol for 35 patients
undergoing ACDF and laminoplasty for cervical spondy-
lotic myelopathy. Compared to a control group of 20 pa-
tients, the ERAS group had a significantly shorter average
LOS (5.62 vs 9.85 days, p < 0.01). Additionally, short-term
(≤ 30 day) visual analog scale and Japanese Orthopaedic
Association scores were significantly improved in the
ERAS cohort.
Venkata and van Dellen50 described the implementa-
tion of an enhanced-recovery program utilizing extensive
patient counseling, preemptive coordination of disposition
needs, limitation of opioid medications, emphasis on early
mobilization, and avoidance of drains and blood transfu-
sions in patients undergoing open surgery for degenerative
lumbar (n = 187) and cervical (n = 50) conditions. The in-
vestigators successfully achieved same-day discharge for
many patients with few readmissions within 30 days and
no long-term complications.
Discussion
The majority of reviewed studies found that implemen-
tation of enhanced-recovery protocols in spine surgery
was feasible and associated with a shorter LOS and ac-
celerated return to function without increasing rates of
Neurosurg Focus  Volume 46 • April 2019 5
Elsarrag et al.
complications or readmissions. This benefit was observed
across several procedures and patient cohorts. Common el-
ements seen in many enhanced-recovery pathways are the
utilization of minimally invasive surgery when possible,
use of multimodal analgesia, and early rehabilitation and
enteral nutrition.
The use of minimally invasive approaches is increas-
ingly common in spine surgery.24 Several of the reviewed
studies incorporated these techniques as part of their en-
hanced-recovery pathways. Numerous systematic reviews
and meta-analyses18,34,39 have found minimally invasive
spine surgeries to be associated with shorter LOS, while
having comparable long-term outcomes. Nevertheless,
surgical planning must consider other variables besides
recovery time and ultimately is to be decided on a case-
by-case basis.
Although several of the aforementioned ERAS proto-
cols differed in the exact analgesic regimen, multimodal
pain control was a common theme. In their article on
perioperative principles related to complex spine surgery,
Lamperti et al.27 listed and reviewed evidence surrounding
several nonopioid medications that may be utilized to de-
crease postoperative pain. Given the extensive side effect
profile of opioid medications, the use of adjunct analgesics
whenever possible is encouraged.
There is evidence that early oral intake after surgery
is safe and may hasten return of bowel function and re-
duce the duration of hospitalization in other surgical
disciplines.9,17,23,37,55 While evidence targeted specifically
at spine surgery is lacking, acceleration of postoperative
enteral nutrition was a cornerstone of many of the afore-
mentioned enhanced-recovery programs and is routinely
incorporated in ERAS pathways in other surgical fields.33
The benefits of early mobilization following spine sur-
gery and other procedures were reviewed by Epstein.12
Many studies revealed reduced rates of infections and
medical complications along with decreased average LOS
after instituting early-mobilization protocols. In addition
to hastening a return to baseline level of function, acceler-
ated ambulation and rehabilitation also serve to emphasize
the patient’s role in recovery.
The majority of studies we found examined the ben-
efits of ERAS for degenerative disease and stenosis of the
lumbar spine. While these are certainly among the most
commonly encountered pathologies, we especially note a
lack of investigations addressing adults undergoing recon-
struction for spinal deformity and degenerative scoliosis.
This is an important area of further research given the
rising frequency of and tremendous costs associated with
correction of adult spinal deformity.58 Lastly, no studies
addressed intradural lesions of the spinal cord itself; these
surgeries may also be amenable to the application of en-
hanced-recovery principles.
Despite the increasing rates of spine procedures,26 stan-
dardized criteria for perioperative management for specif-
ic surgeries are lacking. This variation in practice may be
a cause of extended hospitalizations in patients undergoing
lumbar and cervical spine surgeries.1,2 Given their nature
as evidence-based platforms intended to streamline care
and reduce waste, enhanced-recovery strategies enforce
the use of standardized principles to minimize variations
6 Neurosurg Focus  Volume 46 • April 2019
in practice among surgical teams. Enforcing consistency
of postoperative care may underlie some of the benefit im-
parted by the adoption of ERAS programs.
There are limitations to the reviewed data and our study
that should be noted. As there is no technical definition for
an ERAS protocol, there is a risk of bias at the reporting
level when deciding which studies to include. A quantita-
tive synthesis was not performed due to heterogeneity in
the reviewed studies with regard to design, populations,
procedures, methods, and outcomes. Not all studies had
formal control groups. Some outcomes, such as pain con-
trol and cost, were not reported across all studies. We
therefore focused on outcomes that were most likely to
be consistently reported. Lastly, many studies compared
rates of complications between intervention and control
groups; however, the exact definition of this outcome var-
ied among studies.
Conclusions
Current evidence surrounding the use of ERAS pro-
tocols in spine surgery is largely restricted to retrospec-
tive reviews of nonrandomized data sets and preliminary
cohort studies lacking formal control groups. These in-
troductory studies have demonstrated the potential of
enhanced-recovery protocols to reduce LOS, acceler-
ate return of function, minimize postoperative pain, and
save costs. Rigorous RCTs may serve to provide robust
evidence and establish the efficacy of enhanced-recovery
programs for particular patient populations and proce-
dures within spine surgery. Indeed, Ali et al.3 provided
a detailed protocol for a future multicenter RCT to test
improvements in healthcare quality associated with im-
plementation of an ERAS pathway in patients undergo-
ing elective spine surgeries. Given the nature of ERAS
programs as quality improvement initiatives, continuous
data-driven reassessment and optimization are integral to
ensure excellent outcomes.
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Disclosures
The authors report no conflict of interest concerning the materi-
als or methods used in this study or the findings specified in this
paper.
Author Contributions
Conception and design: Elsarrag, Soldozy. Acquisition of data:
Elsarrag. Analysis and interpretation of data: Elsarrag, Patel.
Drafting the article: Elsarrag, Soldozy, Patel. Critically revising
the article: Kalani, Elsarrag, Soldozy, Patel. Reviewed submitted
version of manuscript: all authors. Approved the final version of
the manuscript on behalf of all authors: Kalani. Administrative/
technical/material support: Kalani, Norat, Sokolowski, Park, Tvr-
dik. Study supervision: Kalani, Norat, Sokolowski, Park, Tvrdik.
Correspondence
M. Yashar S. Kalani: University of Virginia Health System, Char-
lottesville, VA. kalani@virginia.edu.